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  1. Hagan, Joseph ScD, MSPH
  2. Walden, Marlene PhD, APRN, NNP-BC, CCNS, FAAN
  3. Brand, Melinda Colleen PhD, APRN, NNP-BC


Background: Many inpatient healthcare institutions' nurse staffing plans systematically assign fewer patients to nurses when patient acuity is high, but the impact of this strategy on components of nurse stress has not been thoroughly investigated.


Purpose: To examine the relationship between nurse-to-patient ratio assigned based on NICU patient acuity with the Nurse Stress Scale (NSS) subscales Death and Dying, Conflict with Physicians, Inadequate Preparation, Lack of Support, Conflict with Other Nurses, Work Load, and Uncertainty Concerning Treatment.


Methods: A survey including the NSS tool items, demographic questions, and a question about nurse-to-patient ratio during the shift was administered. Cronbach's [alpha], linear regression, and Spearman's correlation were used for data analysis.


Results: Analysis of the 72 participating NICU nurses' survey responses showed fewer patients per nurse during the shift was negatively correlated with stress related to Death and Dying (P < .001) and Uncertainty Concerning Treatment (P = .002) subscale scores. This inverse relationship remained significant after controlling for education and years of experience.


Implications for Practice: The observed higher stress can be inferred to be due to high patient acuity since fewer patients are assigned to nurses caring for high-acuity patients. Improvements in communication to nurses about patients' medical condition, treatment rationale, and information that should be conveyed to the family could reduce nurse stress from treatment uncertainty. Targeted education and counseling could help nurses cope with stress due to patient deaths.


Implications for Research: Interventions to reduce stress related to treatment uncertainty and death of patients among NICU nurses caring for high-acuity infants should be developed and evaluated.